SHIFTING PHYSICIAN PRESCRIBING TO A PREFERRED HISTAMINE-2-RECEPTOR ANTAGONIST - EFFECTS OF A MULTIFACTORIAL INTERVENTION IN A MIXED-MODEL HEALTH MAINTENANCE ORGANIZATION

OBJECTIVES. This study was undertaken to determine whether a program o f education, therapeutic reevaluation of eligible patients, and perfor mance feedback could shift prescribing to cimetidine from other histam ine-2 receptor antagonists, which commonly are used in the management of ulcers and reflux, and reduce costs without increasing rates of ulc er-related hospital admissions. METHODS. This study used an interrupte d monthly time series with comparison series in a large mixed-model he alth maintenance organization. Physicians employed in health centers ( staff model) and physicians in independent medical groups contracting to provide health maintenance organization services (group model) part icipated. The comparative percentage prescribed of specific histamine- 2 receptor antagonists (market share), total histamine-2 receptor anta gonist prescribing, cost per histamine-2 receptor antagonist prescript ion, and the rate of hospitalization for gastrointestinal illness were assessed. RESULTS. In the staff model, therapeutic reevaluation resul ted in a sudden increase in market share of the preferred histamine-2 receptor antagonist cimetidine (+53.8%) and a sudden decrease in ranit idine (-44.7%) and famotidine (-4.8%); subsequently, cimetidine market share grew by 1.1% per month. In the group model, therapeutic reevalu ation resulted in increased cimetidine market share (+9.7%) and decrea sed prescribing of other histamine-2 receptor antagonists (ranitidine -11.6%; famotidine -1.2%). Performance feedback did not result in furt her changes in prescribing in either setting. Use of omeprazole, an ex pensive alternative, essentially was unchanged by the interventions, a s were overall histamine-2 receptor antagonist prescribing and hospita l admissions for gastrointestinal illnesses. This intervention, which cost approximately $60,000 to implement, resulted in estimated annual savings in histamine-2 receptor antagonist expenditures of $1.06 milli on. CONCLUSIONS. Annual savings in histamine-2 receptor antagonist exp enditures after this multifaceted intervention were more than implemen tation costs, with no discernible effects on numbers of hospitalizatio ns. The magnitude of effect and cost savings were much greater in the staff model; organizational factors and economic incentives may have c ontributed to these differences. More research is needed to determine the generalizability of this approach to other technologies and manage d care settings.